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Standard Insurance Company
Certification of Health Care Provider for
Family Member’s Serious Health Condition
866.756.8116 Tel 866.751.5174 Fax
PO Box 3877 Portland OR 97208
To Be Completed by Employee
Employee’s Name
Patient’s Name
Relationship of patient to employee
If patient is employee’s son or daughter, date of birth
To Be Completed By Health Care Provider
INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the FMLA, and/or other
leave laws or policies, to care for your patient. Answer, fully and completely, all applicable parts below. Several questions seek
a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based
upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,”
“unknown,” or “indeterminate” may not be sufficient to determine coverage. Limit your responses to the condition for which the
employee needs leave.
Note: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except such information required to make
a determination that the person is eligible to take the leave, or as otherwise specifically allowed by this law. To comply with this law, we
are asking that you not provide any genetic information when responding to this request for medical information. “Genetic Information”
as defined by GINA, includes an individual’s family medical history (excluding the medical history of the family member whose condition
necessitates this leave) , the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family
member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member
or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
PART A: MEDICAL FACTS
1. Approximate date condition commenced:
Probable duration of condition:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
 Yes  No
If so, dates of admission:
Date(s) you treated the patient for condition:
Was medication, other than over-the-counter medication, prescribed?
 Yes  No
Will the patient need to have treatment visits at least twice per year due to the condition?
 Yes  No
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
 Yes  No
If so, state the nature of such treatments and expected duration of treatment:
2. Is the medical condition pregnancy?
 Yes  No
If so, expected delivery date:
3. Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may
include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
PART B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient’s need for care by the
employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the
provision of physical or psychological care:
4. Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery?
 Yes  No
Estimate the beginning and ending dates for the period of incapacity:
During this time, will the patient need care?
 Yes  No
Explain the care needed by the patient and why such care is medically necessary:
SI 14602
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(9/11)
Standard Insurance Company
Certification of Health Care Provider for
Family Member’s Serious Health Condition
866.756.8116 Tel 866.751.5174 Fax
PO Box 3877 Portland OR 97208
5. Will the patient require follow-up treatments, including any time for recovery?
 Yes  No
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment,
including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary:
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?
 Yes  No
Estimate the hours the patient needs care on an intermittent basis, if any:
________ hour(s) per day; ________ days per week from _________________ through _________________
Explain the care needed by the patient, and why such care is medically necessary:
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities?
 Yes  No
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the
duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode every 3 months lasting 1-2 days):
Frequency: ______ times per ______ week(s) ______ month(s)
Duration: ______ hours or ____ day(s) per episode
Does the patient need care during these flare-ups?
 Yes  No
Explain the care needed by the patient, and why such care is medically necessary:
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
Health Care Provider’s Name
Date
Address
City
Phone No.
Fax No.
State
ZIP
Specialty/Type of Practice
I certify that the information on this form is accurate and truthful to the best of my knowledge.
Signature of Health Care Provider
SI 14602
Date
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